Psychological and financial impact of the COVID-19 pandemic during the first stages of the pandemic: Brazilian orthodontists´ perspective

ABSTRACT Introduction: Brazil faced a catastrophic situation in the coronavirus pandemic. Due to the high risk of contamination and spread of COVID-19, dentist have been attending only urgency and emergency services in Brazil at the beginning of the pandemic. Objective: This research aimed to evaluate the psychological and financial impacts caused by the coronavirus pandemic in Brazilian orthodontists. Methods: This population-based cross-sectional study collected demographic data and mental health measurements from 404 orthodontists. Depression, anxiety, insomnia, and distress were evaluated through Brazilian versions of the 9-item Patient Health Questionnaire (9-PHQ), the 7-item Generalized Anxiety Disorder scale and Mini-Tracking (GAD), the 7-item Insomnia Severity Index (ISI), and the 22-item Impact of Event Scale-Revised (IES-R), respectively. The demographic data of the sample was described using descriptive statistics. The data was analyzed according to sex, professional status, and economic income. Comparisons were performed using Chi-square tests, Mann-Whitney U tests, and Kruskal-Wallis followed by post-hoc tests. Results: Females, graduate students, and lower incomes subgroups showed higher levels of depression, anxiety, insomnia, and distress. Most orthodontists showed moderate to extreme financial and professional concerns during the pandemic. Conclusion: The coronavirus pandemic negatively affected the psychological health and increased the financial concerns of the Brazilian orthodontists, mainly female, graduate students, and with income below 10k participants.


INTRODUCTION
In March 2020, the World Health Organization (WHO) declared the coronavirus pandemic, due to the significant increase in the number of reported cases and the global virus spread. 1 In the middle of 2020, Brazil was the epicenter of the coronavirus outbreak in Latin America, presenting the second-highest number of cases and deaths in the world. Until the end of July 2020, more than 2 million cases were confirmed, and 90 thousand deaths were reported in Brazil. 2 In dental practice, both patients and professionals are exposed to a high risk of COVID-19 infections. The frequent exposure to saliva and blood, the proximity between patient and professional, and the aerosol spread increase the contamination risks. 3,4 For this reason, dentists attended only urgency and emergency services during the coronavirus pandemic in Brazil, at the beginning of the pandemic. Elective treatments such as Orthodontics have been postponed until the situation becomes controlled. 5,6 Concerns regarding contamination of dentists due to the transmission of the coronavirus through saliva were previously reported, and safety measures were recommended. 4,[7][8][9] In this context, the coronavirus pandemic may cause physical and mental effects on health workers. The pandemic situation negatively affects psychological health and financial status. 10,11 Symptoms as post-traumatic  5 stress, depression, anxiety, insomnia, and emotional exhaustion have been reported. [10][11][12][13] Therefore, this study aimed to evaluate the psychological, financial, and professional impacts during the first stages of the coronavirus pandemic in Brazilian orthodontists.

MATERIAL AND METHODS
This population-based cross-sectional study was approved by the Ethics Committee on Human Research of University of São Paulo (protocol number N. 4.023.156 CAAE 30984620. 6.0000.5417), and all participants agreed to participate in the survey. Their identities were kept confidential.
The sample size was calculated considering 80% of test power, a significance level of 5%, a design effect of 1, and 50% frequency of psychological symptoms, based on a previous study of the COVID-19 outbreak. 7 According to the Brazilian Federal Council of Dentistry, the population of orthodontists comprised 27940 subjects. 14 Therefore at least 379 completed questionnaires were necessary.  The link was available for 10 days. Participants could refuse or withdraw to participate at any time, leaving the website, without any penalty or loss. All participants also answered 10 additional questions regarding the impact of coronavirus pandemic in financial and professional concerns.
The economic incomes were evaluated in the local currency (Fig 1).

STATISTICAL ANALYSIS
The demographic data of the sample was described using descriptive statistics. The data was analyzed according to sex, professional status, and economic income. Comparisons were performed using Chi-square tests, Mann-Whitney U tests, and Kruskal-Wallis followed by post-hoc tests (p<0.05).

RESULTS
The sample was composed by 404 orthodontists (259 females; 145 males). The demographic characteristics of the sample are described in Table 1.
The severity of depression, anxiety, insomnia, and distress is reported in Table 2. Most of the sample presented mild to severe symptoms of depression (62.4%), anxiety (62.6%), insomnia (50.8%), and distress (82.4%) ( Table 2).    Table 3: Total scores of depression, anxiety, insomnia, and distress in orthodontists, and comparison between sex, professional status, and economic income range.  (Table 3). Greater median scores were observed for females, graduate students, and professionals with lowest incomes (<10k).
Distinct levels of concern were observed among orthodontists regarding the impact of the coronavirus pandemic in the financial and professional activities (Fig 1). Females demonstrated greater concern about payment of office expenses, delay of treatment end, contamination risks, and emergency appointments (Table 4). Professors demonstrated lower concern about patient's dropouts and delays of treatment end, compared to graduate students and clinicians (Table 4).  Damages to patients' oral health (0-4) Delay of treatment end (0-4)  Professionals with highest incomes (>10k) were less concerned regarding the delay of treatment end, contamination risks, and emergency appointments (Table 4).  (Table 2). A similar study conducted in the USA during the same stages of the pandemic showed that dentists reported symptoms of depression and anxiety as well. 33 Negative psychologic impact in healthcare workers have been previously reported during coronavirus pandemic. 7,11,29,32 Also, anxiety and depression are very associated with sleep disturbances. 34,35 Compared with other occupational groups, healthcare workers reported the highest rate of poor sleep quality. 36 Therefore, the concern with mental health is directly related to physical health, and both need attention by the occupational health policies, during the pandemic COVID-19. 7,31 Females were statistically significant more affected than males regarding all psychological symptoms reported in this study (Tables 2 and 3), which agrees with Gibson et al. 37 They stated that female sex is one of the factors that could predict mental health inequalities during the COVID-19 pandemic. This was expected; since females usually report higher anxiety scores than males. 38,39 During the coronavirus pandemic, previous studies showed that adult females also reported higher anxiety scores. 31,40 In addition, moderate to severe symptoms of depression, anxiety, insomnia, and distress was found for female physicians and nurses. 7,41 On the other hand, a similar study con- The authors reported that only 16.7% of the orthodontists had anxiety symptoms, and there was no statistically significant difference when the prevalence of these symptoms was stratified by sex and age. It could be speculated that although both studies were conducted simultaneously, the countries were in different phases of the pandemic. One must also consider the geographic and cultural differences between the two countries.
Graduate participants were significantly more affected than clinicians and professors regarding all psychological issues (Tables 2 and 3). Similarly, graduate students experienced a negative psychological impact of the coronavirus outbreak in China. 31 The results of this study are in accordance with previous reports showing that younger people demonstrated a significantly higher prevalence of anxiety and depressive symptoms than older ones. 36,42,43 So, it could be speculated that graduated students were more affected than clinicians and professors because they are usually younger.
The present research showed significantly greater psychological impact in professionals with income below 10k (Tables 2 and 3).
In Brazil, the postponing of elective dental procedures caused a substantial reduction of orthodontics activities. According to reported that people with financial stress are more vulnerable to mental health issues. 43 A previous study with dental practitioners showed that the negative economic impact of the office closure was subsequently associated with concerns about professional future, anxiety, and fear. 11 Additionally, lower incomes were previously associated with higher levels of distress. 43,45,46 Most orthodontists presented moderate to extreme concerns regarding financial issues, including dropouts of orthodontic treatment and patient's non-payment dues. Interestingly, they were extremely more concerned with patients' dropouts than having a financial emergency personal fund (Fig 1). In addition, orthodontists also showed concern about contamination risks after social isolation (Fig 1). Coronavirus outbreak has affected all sectors in the economy all over the world, and it was not different in Brazil, which already presented a fragile economic situation before the pandemic. The New York Times recently identified dentists as in the highest risk of contamination at that time. 47 Due to these facts, the postponing of the elective dental procedures was strongly recommended, resulting in severe monetary implications for dental practitioners worldwide. 48 In addition, different from other countries, no governmental assistance was provided to Brazilian clinicians. 48,49 Then, orthodontists can be expected to be dramatically concerned about the financial impact that the pandemic will cause during the restart of their dental practices. 50 Lima Regarding differences between sexes, the only financial issue that the female orthodontists were significantly more concerned than males was regarding the payment of office expenses (Table 4). This specific concern agrees with Ferneini, 51 who evaluated the financial impact of COVID-19 in the dental practice. The author stated that the pandemic brought overhead costs because it required the orthodontic team to have a better and safer working environment for the patients, staff, and orthodontists. This will potentially increase orthodontists' business overhead and reduce the profit margin even further.
When evaluating the impact of the coronavirus pandemic on the orthodontists' professional lives, the females showed greater concern regarding the delay of treatment end, contaminations risks and emergency appointments than males (Table 4).
These findings reinforce the greater emotional impact of the pandemic in female orthodontists (Table 3). These sex differences on risk and resilience to stress are complex and varies according to characteristics of the stressful factor, such as type, timing, and duration, as well as changes in brain structure and function. 39 Moreover, health care providers are particularly vulnerable to emotional distress in the current pandemic, due to the exposure risks, and the additional concern about infecting their family and friends. 7 Among the three evaluated groups, professors showed the lowest level of concern regarding patients' dropouts, decreasing number of patients and delay of treatment end ( Table 4).
The delay of treatment end was also a recurring concern among patients during the pandemic. 53,54 It could be thought that graduate students and clinicians have higher levels of patient-related concerns due to the nature of their clinical routine. In the other hand, professors usually have a greater workload dedicated to teaching and research.
Finally, orthodontists with higher incomes showed a lower level of concerns regarding the delay of treatment end, contamination risks and emergency appointments during the isolation period (Table 4). It is not surprising that financial security influences the behavior of orthodontists in other areas of their lives. Higher income has been reported as a beneficial factor for psychological wellbeing. 55,56 A previous study showed that respondents with higher income were happier, more satisfied with their lives, health, achievement, future economic situation, and social conditions. 57 It is important to highlight that the present findings directly

CONCLUSIONS
In this study performed at the beginning of the pandemic: » Brazilian orthodontists reported high rates of symptoms of depression, anxiety, insomnia, and distress. Female, graduate students and income below 10k were the most affected.
» Most orthodontists were from moderate to extremely concerned about financial issues and regarding patient care during the pandemic.
» Female orthodontists showed a higher level of financial concern than their male counterparts. » Professors showed a higher level of financial concern than postgraduate students and clinicians.
» Orthodontists with higher income showed a low level of concern with delay in the orthodontic treatment, contamination after social isolation, and caring of urgencies during the social isolation.